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Behind the paper: Viral load monitoring in Côte d’Ivoire

In this post, we talk to the authors of HIV viral load testing and monitoring in Côte d’Ivoire: A survival analysis of viral load testing and suppression, and evaluation of adherence to national recommendations, which was recently published in PLOS Global Public Health. The authors of the paper are Kathryn E. Kemper, Orvalho Augusto, Stephen Gloyd, Derick A. Akoku, Gbossouna Ouattara, Lucy A. Perrone, Paul Henri Assoa, Chantal Akoua-Koffi, Christiane Adje-Toure, and Ahoua Koné.

What led you to decide on this research question?

Through the implementation of our project, we were lucky to have a great dataset on our hands. The data was collected from a laboratory information system (LIS) in Côte d’Ivoire that processed viral load tests from hospitals and health centers in the regions we were supporting health system strengthening and HIV clinical efforts in. There are very few large datasets with such comprehensive data on viral load testing, particularly coming from the health information systems.

We also believe that viral load monitoring is an understudied topic, especially in many low- and middle-income countries, despite its direct association with the health and wellbeing of people living with HIV. Therefore, we wanted to use this research question to undercover more information about the “third 95” in our 95-95-95 strategy and where gaps occur related to viral load suppression.

Could you talk us through how you designed your study? What was important for your team as you created the study team?

We assembled a retrospective cohort study by leveraging the strength of the dataset, which had a unique study ID for each patient. Therefore, we were able to identify the year of ART initiation as well as the dates of subsequent viral load tests to estimate time between viral load tests. This was key to assessing whether the national guidance on viral load testing was being adhered to.

Our study team was strong because we worked with a group of authors with various expertise in statistical methods, local contextual knowledge, healthcare delivery and/or laboratory experience, and so on.

What challenges did you encounter during your study?

The main challenge we encountered is that it took a long time for us to clean and prepare the data. Because the database was designed as a laboratory information system and not specifically for the purpose of scientific research, there was a lot of missingness which we reported on in the results, especially related to ART initiation date, a key indicator for measuring viral load suppression.

What did you find most striking about your results? How will this research be used?

A striking finding was identifying the gap between first and second viral load tests. While most patients received a viral load test in their first year of ART treatment, a majority never received a second test, or didn’t receive one in a timely manner. This was especially true for patients who were not virally suppressed at their first test. This is a complex and multi-faceted problem, but we hope that by bringing to light this gap, public health actors and medical professionals can work together to address it.

What further research questions need to be addressed in this area?

We would love to learn more about how the COVID-19 pandemic has shaped the landscape of viral load monitoring. In addition, further research could explore and expand upon the gaps we identified, such as not receiving a second routine viral load test as well as low rates of viral suppression among children.

Additionally, qualitative research to better understand data collection practices and gaps would be useful to inform training efforts and future development of information systems and data collection tools/reports.

Why did you choose PLOS Global Public Health as a venue for your article?

We recognize PLOS as a leader in the scientific and public health publishing world and it was an added benefit for us that the University of Washington is part of PLOS Community Action Publishing and PLOS Global Equity programs. This meant 100% of our publication costs were covered and we were able to publish open access, which was important for us in terms of ensuring equitable access to research.

About the authors:

Kathryn Kemper received her MPH from the University of Washington (UW) and BA from UC Santa Cruz (go banana slugs!). She previously worked on implementation science and research projects related to cancer and HIV at the UW Department of Global Health. Kathryn now manages a research initiative focused on improving data infrastructure and research capacity for population health and health equity in the Department of Epidemiology and Biostatistics at UC San Francisco.

Derick Akoku received his PhD in Public Health from the University of Adelaide, Australia. He has worked on research, monitoring, and evaluation of public health projects including HIV, TB and Malaria. Derick Akoku now works on global health and international development projects and has a passion to make a genuine contribution towards the achievement of the sustainable development goals.


Steve Gloyd is a family practice physician who has been a University of Washington faculty member since 1985. He has worked for over 40 years globally as a clinician, manager, researcher, teacher, and activist, focusing on social justice and improving primary health care. He received his BA and MPH from Harvard, his MD from the University of Chicago, and his family medicine residency at the University of Washington.

Orvalho Augusto is a physician trained in Mozambique who has worked in public health research for over a decade. He received an MPH degree from the University of Washington, USA. Currently, he has been working on Implementation Science methods application for HIV, TB, malaria, and health systems analysis.

Ahoua Koné is a native of Côte d’Ivoire and a faculty member at the University of Washington Department of Global Health. She received her BS and MPH from the University of Washington and her JD from Seattle University School of Law. Her work over the last two decades has included teaching and mentoring, leading multi-country implementation and research projects, legal representation of marginalized individuals and advocacy actions to promote equity and social justice.

Disclaimer: Views expressed by contributors are solely those of individual contributors, and not necessarily those of PLOS.

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